The American healthcare system is anything but straightforward.

Maybe you've finally found a therapist you want to work with only to realize you have to figure out whether they're in-network, what your deductible is, if you need a referral, or why your Explanation of Benefits says one thing while your bill says another. It's enough to make anyone want to close the browser and try again another day.

Unfortunately, that's often exactly what happens. The process of navigating health insurance is confusing, time-consuming, and can become a barrier to getting care in the first place.

As a therapist and someone who works closely with insurance every day, I see firsthand how much unnecessary stress these systems create. We expect people to make important decisions about their healthcare using terms they were never taught and policies that can be difficult to interpret.

My hope is that this guide makes things a little clearer. Below, I'll break down some of the most common insurance terms, explain what they actually mean, and share practical questions you can ask your insurance company before starting therapy or any other healthcare service.

Health Insurance Terms, Explained

Oh you know…deductibles. Copays. Coinsurance. In-network. Out-of-network. Explanation of Benefits. Superbills.

If your eyes glazed over reading that list, we don't blame you and we’d really like it if you kept reading! You don't need to memorize every insurance term, but understanding a handful of the most common ones can help you ask better questions, understand what your plan actually covers, avoid unexpected costs, and feel more confident when seeking care.

Here are the insurance terms you're most likely to encounter when accessing therapy services at practices like The Expansive Group—along with what they actually mean. Bookmark this! 

*We use "you" throughout this guide instead of "the client" to make these definitions easier to follow. Keep in mind that not every term will apply to every insurance plan or situation.*

• Deductible: The amount you’d pay for health care services before your insurance begins to pay towards your health care fees. 
  
  • E.g., Your therapist charges $150 for a session. In order for your insurance to start paying for some of your therapy costs, you need to spend your minimum deductible first. Let’s say your deductible is $500, you need to pay the full price of $150 per session until you meet $500. Once you’ve met $500, your insurance will start to cover some of your session costs.  

• In-Network (INN): Your insurance plan is contracted with The Expansive Group (or another provider) to provide you with a reduced rate for services, and in most cases, share the financial burden of those services.
  
  • E.g., Your therapist charges $180 per session, but because they're in-network, your insurance has negotiated that visit down to $120. If your copay is $30, you'll pay $30 and insurance pays the remaining $90.

• Out-of-Network (OON): Your insurance plan is not contracted with The Expansive Group (or another provider), and therefore your cost is our full rate (or a negotiated sliding scale rate). You’d have to cover the cost of sessions fully out-of-pocket. Some plans offer out-of-network reimbursement, so make sure to check your out-of-network benefits!
  
  
• Superbill: An itemized bill listing the services received in a given time period, which you can use to submit to your insurance to pursue out-of-network reimbursement for services you paid out-of-pocket for.
  
  • E.g., Your out-of-network provider charges $200 out-of-pocket for each session, and you meet twice a month. At the end of the month, you submit a superbill to your insurance, which states that you’ve paid $400 in total for services. Your insurance reimburses a portion of the costs via direct payment to you based on your out-of-network benefits. 

• Copayment/”Copay”: A copay is a fixed amount, as outlined in your insurance policy, that you pay for a health care service.
  
  • E.g., Your copay may be $20 per therapy session, while insurance covers the rest of the cost.

• Coinsurance: Coinsurance is an alternative way that insurance plans determine your share of the costs of a health care service. This is calculated as a percentage and typically comes after a deductible is met. 
  
  • E.g., Insurance covers 80% of the cost of service, leaving you with the remaining 20%.

• Allowed amount: The amount that your insurance company is willing to provide coverage for, which is especially important to know when submitting out-of-network claims. 
  
  • E.g., if you paid your TEG provider $150 out-of-pocket and your coinsurance for out-of-network services is 50%, you may not receive a full $75 in reimbursement if your health insurance company assigns a lower allowed amount to the service than what you paid out-of-pocket.

• CPT code: This stands for Current Procedural Terminology and is a 5-digit code created by the American Medical Association to describe a healthcare service. This code is used for healthcare billing to describe the service rendered. You can use this code to make sure that the exact service you’re receiving is covered by your insurance. Your provider (or their billing department) should be able to give you the CPT code for the service you’re receiving. 

• Claims: is a formal request for payment submitted by a healthcare provider (or patient) to an insurance company after services are rendered.
  
  • E.g., you go to therapy and your therapist charges $150 for the session. Afterward, your therapist submits a claim to your insurance company saying what service you received and how much it cost. Your insurance company reviews the claim to determine how much they’ll pay and how much you owe.

• Explanation of Benefits (EOB): is a statement sent by a health insurance company detailing how a medical claim was processed, showing services received, the amount billed, what the insurer paid, and what the patient owes. It is not a bill, but it’s helpful to have in your records so you can make sure that your insurance provided coverage correctly. 

• Coordination of Benefits (COB): is the process insurance companies use to determine the payment order when a person is covered by more than one health or dental plan, ensuring they don't overpay. If you hold more than one insurance plan, you need to perform a Coordination of Benefits every 6 months while multiple plans are active. You need to identify a primary payer (who will pay first) and a secondary payer (who will pay the remaining costs) to avoid duplicate payments, reduce costs, and streamline claims.

• Authorization: often called prior authorization or pre-certification, is a health plan process requiring providers to obtain advance approval from an insurer before delivering specific services.
  
  • E.g., Rarely, your insurance plan might require a prior authorization before they will cover your mental health services. In this situation, you’d need to contact your insurance provider before starting therapy to make sure they’ll cover the services. This is a more common practice for higher-cost treatments, like Intensive Outpatient Programs. 

• Referral: is a formal request that directs a patient to a specialist or for special medical services.
  
  • E.g., You want to start therapy, but your HMO needs you to first visit your family doctor. Once you've met with your doc, they'll send a referral to a mental health provider so your insurance will cover the visits.

‍Tips for Navigating Health Insurance

Unfortunately, it is common to experience miscommunication or receive inaccurate information when speaking with insurance representatives. Do not be afraid to double-check your understanding or call back another time to speak with someone else. It can also be helpful to connect with a provider’s billing department so that they can guide you through the best questions to ask.

 At The Expansive Group, our billing specialist is available to speak to any prospective or current clients who want to understand their insurance benefits for mental health services. 

How to Talk to Your Insurance Company

On the back of your insurance card, there should be a number next to “Customer Service” or “Member Services.” This is the number that you can call to get your questions answered. Typically, calling first thing in the morning will give you the shortest wait times. 

To get you started, here are a couple of questions that may be important to ask:

• Is The Expansive Group (or insert provider name here) an in-network provider with my insurance plan?
• What is my coverage for outpatient psychotherapy services? 
  
  • For example: The specific CPT code for the service would be 90837. 
• What is my annual deductible? How much of my deductible have I met? Does my deductible apply before I can receive coverage for outpatient psychotherapy services? When does my deductible reset?
• Do I need any authorizations or referrals before seeing an outpatient mental health provider?
• [If TEG is out of network] What is the process for submitting a superbill for out-of-network reimbursement? How much can I expect to receive in reimbursement and how long does processing take? 

It’s a great idea to ask for a Call Reference  phone number so you can refer back to this conversation with a future customer representative if needed.

One other thing: if you are looking for couples therapy, only one of you needs to have in-network health insurance. The policyholder will also be the designated client who will need to hold the diagnosis. For couples therapy, the CPT code we use is 90847, so be sure to ask about this service because not all plans offer the same coverage for couples/family therapy. 

Please Don’t Give Up! 

Many people are left in the dark about their health insurance benefits, especially when it comes to mental health services. Many people avoid seeking mental health care because we may assume that these services aren’t covered. But did you know there is a federal law that ensures mental health services are given the same insurance coverage as medical services? This article does a great job of breaking down this parity law, so you can better understand how this law works for you. 

It’s easy to feel defeated in the face of these complicated systems that are not designed to be accessible. But if you do have access to health insurance, we encourage you to take advantage of your benefits as best as possible, because you deserve access to the care you need!

If this article left you with any other questions, please feel free to reach out to our billing department at billing@theexpansivegroup.com. We’d be happy to help!

Image Credit: The Good Place